The proposed review into physician associates (PAs) and anaesthesia associates (AAs) by Professor Gillian Leng has come under fire from doctors and others. Their concerns have led Baroness Bennett to call for a House of Lords debate to examine the scope of the review, which will take place on 5 December.
I have a huge respect for Gillian Leng – she used to run the National Institute of Clinical Excellence, so she is used to scrutinising evidence. But there are doubts from the medical profession about the breadth of the review, given that there are no plans for a pause before the review is complete.
However, a cautious welcome is what is required. Caution, though, as the ink had barely dried on the Leng review press release when we got anonymous briefings from a ‘senior NHS source’ to the BBC. In the headlined piece: “A toxic staffing row is splitting the NHS”, it detailed incidents where both PAs and AAs felt they were side-lined by doctors working in hospitals.
If only I had been aware of an undercover BBC Panorama report on PAs in primary care in 2022, I would have kicked up more of a fuss earlier. One of the GP practice managers let the cat out of the bag by stating that they hired PAs as “they were cheaper than GPs.”
This was similar to the criticism the family of Susan Pollitt made after the inquest into her 2023 death. The coroner concluded that her death was caused by an “unnecessary medical procedure, contributed to by neglect.” Her widower, Roy stated that “she would have lived if the NHS had not used cheap labour.”
What are Physician Associates and Anaesthesia Associates?
These associates are a relatively new NHS staff group who have been subject to much controversy of late. A Physician Associate is a healthcare professional trained to work under the supervision of doctors, providing medical care including diagnosis and management, while an Anaesthesia Associate assists anaesthetists in delivering anaesthesia and perioperative care, ensuring patient safety during surgical procedures. To qualify, they undergo two years of postgraduate training after completing a relevant degree, typically in biomedical, life sciences or healthcare.
They are not currently subject to any form of statutory regulation. Following a 2017 consultation, the government decided that the General Medical Council should be their regulator, which is due to begin next month.
However, I highlighted over a year ago that their regulation should be delayed until their ‘scope of practice’ – what they can and cannot do (in effect, their job description) – was defined. Instead, as I commented previously, the legislation was pushed through with minimal scrutiny.
Two key bodies involved in the issue are the Royal College of Physicians (RCP), which promotes medical education and sets clinical standards, and the General Medical Council (GMC), which regulates doctors, sets ethical standards, and ensures patient safety.
As a result of the patient safety concerns (following the deaths of Emily Chesterton, Ben Peters and Christopher Tucker), the RCP held an extraordinary general meeting (EGM) in March. However, this meeting was “delayed inappropriately” until after parliament had passed the 13 March statutory instrument giving the GMC the regulatory powers. This led to multiple resignations, including the president, as well as letters to the Health Select Committee. They declared that parliament had been “misadvised” over the legislation following an independent review by the King’s Fund of the circumstances leading up to the calling of the EGM.
Looking to the future
Next month the General Medical Council (GMC) will take over as the regulator of PAs and AAs without having defined their scope of practice. They will rely on employers individually to define this. Given that both a lack of scope and issues of supervision were key to the criticism at the inquests, this has led to the threat of legal action against the GMC by a group of doctors and patients.
With a new government comes new opportunities, and one can have sympathy for the new health secretary on how to deal with this dog’s dinner he has inherited.
The medical education establishment failed by not ensuring a national scope was defined before the legislation was implemented. The educational cart has been put before the PA and AA horse. Despite the GMC’s refusal to define a national scope, the RCP is likely to attempt to set this out, literally days before the GMC takes over regulation.
Meanwhile the British Medical Association (BMA) (the a trade union that represents doctors) has already set out a scope of practice document. The Royal College of Anaesthetists has set out an extensive draft scope document for AAs.
Patients’ thoughts
What should patients make of this? Patients must have confidence in all the health-care staff they are dealing with. They must believe that all staff know what their limits are and what they can and cannot do, and whom to seek help from if they need assistance. The Leng Review will not report until Spring next year. It is vital that all groups, especially patients, submit to this review.
The government announcement on the Leng review was enthusiastically welcomed by Charlie Massey of the GMC as an “important step”. On social media, the Chief Medical Officer of the NHS, Stephen Powis, welcomed the review. Bear in mind these were many of the same people or organisations who made no comment when serious governance concerns were raised.
Professor Powis was one of many in the medical establishment who was in the room in March at the RCP extraordinary general meeting when in a “jaw dropping moment” I pointed out instances where a PA had been presented as an ‘expert witness’ in child protection cases, after I was contacted by a whistle-blower. It wasn’t until the Daily Telegraph ran the story six months later, that any action was taken.
Further, despite the clear statement from both the RCP and the Department of Health following the meeting that PAs should not replace doctors, this is still happening.
Scrutiny is welcome
So although the Leng review is welcome, as is the Baroness Bennett debate, with a workforce in crisis, fewer students applying to do medicine and government delays in the expansion of doctors, there are powerful people pushing for the NHS Workforce Plan to be implemented as is, without further scrutiny.
Finally, just because there is a review, this doesn’t mean anything will change, even if the government recommends implementation. Following the 2018 Williams review, it was recommended that the GMC loses its right of appeal in medical tribunals, but it still persists in appealing decisions made by the Medical Practitioners’ Tribunal Service.
On 28 November, the RCP updated its position on physician associates: “At the 19 November meeting of the RCP council, it was agreed that there is a limited role for PAs working in secondary care in the medical specialities as long as they are supported by clear supervision arrangements, professional regulation and a nationally agreed scope of practice.”
So, do I welcome Wes Streeting’s review? As the fictional Sir Humphrey would say, with a wry expression: “Yes Minister”.
